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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT SC 304 E WEBER AVE - 3 -FL - STOCKTON CA 95202 - (209) 458-3420 Amount Date SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT I YEAR FROM DATE ISSUED INFO NON-REFUNDAR1LE PERMIT CALL 209 953-7697 FOR INSPECTIONS jEXPIRES t V ( A Service Re uest# } ! L C'3 f'S }j SILL CITYJZTP DDRESS J �' PARCEL SIZE "F'T `A' r1L. APN t'�%l✓Zl -� ✓ 1Li.;,l ^ _ J�-, S STREET FOWNERADD�RESS ONSITE WASTEWATER PERMIT 42-02-001 R NAME _S`?f` ."\ V ? sz) .. 12R2l2003 i ^a - 1\ CITYISTATFJZIP - V ;3 1 r i , �i' � `�� Jy r, PHONE u J'\ CONTRACTOR Y. --r 1� �� ,. j�w�.� IN Y� CITYISTATElZIP ;^•/ li , C... f� ��-'-'r CONTRACTOR ADDRESS i LICENSE ❑ C-02 ❑ C-36 OTHER NUMBER EXPIRATION DATE WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y N h i C1 BUILDING PERMIT # LAND USE APPLICATION # .1 SY PERC TEST Of AEW LJREPAIRIADDITION ❑ ENGINEER DESIGNED (ALTERNATIVE - TYPE OF WORK: [3 INSTALLATION ❑ REPLACEMENT ❑ DESTRUCTION INSTALLATION WILL SERVE: ❑RESIDENCE ❑ -COMMERCIAL ❑ OTHER Nu M BER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: ❑ SEPTIC TANK TYPE/MFG CAPACITY gal # OF COMPARTMENTS ❑ CREASE TRAP TYPE/MFG CAPACITY gal # OF COMPARTMENTS L)PKG TX PLANT DISTANCE TO NEAREST: WELL it FOUNDATION ft PROPERTY LINE fl 'i 1 I TYPEOP PUMP ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) : -t ❑ LIFT STATION SIZE ❑ LEACH LINES ❑ LEACHING CHAMBERS # OF LINES LENGTH OF LINES ft { DISTANCE TO NEAREST WELL ft FOUNDATION it PROPERTY LINE ft ft ❑ FILTER BED WIDTH ft LENGTH R DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ❑ MOUNDED WIDTH ft LENGTH R DEPTH ft ft DISTANCE. TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ❑ SUMPS WIDTH ftLENGTH ft DEPTH ft ft + I DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE iii ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ft fl DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE i ❑ SEEPAGE PITS NurviseR WIDTH ft DEPTH fi ft i DISTANCE TO NEAREST WELL R FOUNDATION ft PROPERTY LINE I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQU IN COUNTY ' ORDINANCES, STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. Final Inspection By Date LJ �51`kA-IAL rEKlvu I-.vppluvcu uy Character of Soil fo Depth Of 3 Ft: P.itlSump Soil Character: COMMENTS r(� PE SC Received [ Chec ki " Amount Date termor Invoice # Permit IDN Code INFO B Cast) Remitted Service Re uest# f� E ONSITE WASTEWATER PERMIT 42-02-001 12R2l2003 4